Allegation:
Negligent prescribing and monitoring of narcotic medications for chronic pain resulted in addiction and death.
The Case:
A 48 YOF (5’ 1.5”, 168 lbs.) presented to the ED with complaints of dyspnea, increasing shortness of breath, chest congestion, and wheezing. The patient was a moderately heavy smoker for many years with a medical history significant for COPD, chronic back pain, and anxiety.
The patient was admitted by a hospitalist. Lab studies were within normal limits. The admitting CXR showed hyperinflation consistent with advanced COPD and right hilar enlargement suspicious for tumor. No pleural effusions were identified. The patient’s admitting diagnosis was COPD exacerbation, probable left pneumonia, chronic migraine, chronic pain syndrome on narcotics, and possible right hilar enlargement.
The patient was discharged 4 days later with diazepam 5 mg Q12H and oxycodone 15 mg Q6H to the care of the defendant family medicine physician (FM) who had followed her for chronic pain for over 22 years. The following week, the patient presented to her FM complaining of chronic lumbosacral pain. The FM prescribed oxycodone 30 mg 120, oxycodone 15 mg 120 for breakthrough pain, and diazepam 5 mg Q12H. Ten days later, the FM refilled the patient’s prescriptions due to complaints of ongoing chronic pain.
Five weeks after her discharge, the patient’s husband brought her to the FM’s office unresponsive in the back seat of his car. The FM was unable to arouse the patient and advised she be taken directly to the ED. The patient’s husband commented that the patient over-medicated between 4 and 5 days per week. Upon arriving at the ED, the patient was admitted for respiratory depression. Four days later, the hospitalist discharged the patient with medications that included diazepam 2.5 mg bid, and oxycodone 15 mg Q6H PRN for severe pain. The hospitalist noted, “I have asked her to try not to exceed this dose” and to follow up with her FM. Further, he wrote “I strongly recommend that she be limited in terms of the amount of oxycodone that she has available, if at all possible, to prevent this from happening again...”
One month later, the patient returned to her FM who renewed her prescriptions without changes. Also, the FM and his drug abuse counselor met with the patient who signed a new pain contract that specified that the patient’s husband be present when her medications are dispensed.
Approximately three weeks later, the patient called her FM’s office stating that her prescriptions were soon due and asked if she could pick them up without her husband present. He was working out of state for the next three months. The FM renewed the patient’s prescriptions without changes and made an appointment for 2 weeks out. The patient failed to keep her appointment and the FM terminated the physician-patient relationship in writing due to violations of her drug contract.
The patient then presented to a new family practice physician for continued treatment of chronic pain, COPD, CHF, and several other co-morbidities. For the next three years, she was treated with numerous maintenance medications including clonazepam, norco, roflumilast, and nifedipine. Ten weeks after her last appointment with the family practice physician the patient’s husband found her on their sofa, cold and unresponsive, and she was later pronounced dead.
A post-mortem toxicity screen was positive for: clonazepam, 7-aminoclonazepam, cannabinoids, THC, hydrocodone, analgesics, acetaminophen, amitriptyline, nortriptyline, and stimulants (caffeine). No autopsy was performed, and the death certificate listed the cause of death as respiratory arrest due to pharmacologic intoxication. The patient’s husband sued her original FM alleging negligent prescribing of opioid medications caused her addiction which ultimately led to her death.
Expert Testimony
Plaintiff experts stated that the patient should have been more closely monitored by documenting the patient’s drug tolerance, and that the physician should have investigated and monitored the patient’s functional level. Additionally, these experts opined that the physician breached the standard of care by not justifying higher doses of narcotics given the decedent’s COPD. As to causation, the expert suggested that the FM’s negligent prescribing caused the decedent’s opioid addiction, and the rewiring of her brain chemistry making her prone to addictive tendencies. Although the defendant was no longer prescribing the drugs, the patient’s addiction tendencies contributed to her death.
Experts for the defense opined that the defendant met the standard of care in his treatment of the decedent, and that his care was not a proximate cause of her death. One expert noted that the defendant was not escalating the dosages and that the decedent reported that the dosages relieved her chronic pain. There was no indication of drug diversion or abuse. A defense expert noted that the defendant and his addiction counselor met with the decedent, required a new drug contract, and insisted that the decedent’s husband attend office visits. When she failed to comply with those requirements, he discharged her from his practice. None of the defense experts linked the defendant's actions to the decedent’s death three years later.
Resolution
A jury trial resulted in a verdict for the defense.
Risk Reduction Strategies
To mitigate the risk of patient overdose when initiating and continuing chronic opioid therapy (COT), regularly assess the harms and benefits of opioids in chronic pain management and thoroughly document the assessments.
Be knowledgeable of the many resources and tools available that address opioid prescribing for chronic pain, including the Centers for Disease Control and Prevention’s Summary of the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain, which contains a link to the full guideline.
Check the prescription drug monitoring program (PDMP) website in your state if one is available. (See the Federation of State Medical Board’s Prescription Drug Monitoring Programs: State-by-State Overview for a state-by-state list of PDMP websites.)
---
If you have questions on this topic, please email RiskAdvisor@ProAssurance.com or call 844-223-9648.